Children and Young People’s Disability Registration Form

Children and Young People’s Disability Registration Form

Nottinghamshire
I/we agree that the information submitted by this form can be shared with my Local Authority for the purpose of providing services.*

Yes
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Child/Young Person's Details
Name of child or young person*

First NameMiddle NameLast Name
Gender

MaleFemale
Date of Birth

DayMonthYear
Address

Street Address

Street Address Line 2

CityCounty

Postcode
Borough/District (e.g. Gedling, Bassetlaw, etc)
Ethnicity

Parent/Carer Details (1)
Name

PrefixFirst NameMiddle NameFamily Name
Email
example@example.com
Telephone

Area CodePhone Number
Is address same as child/young person's?

Yes
Address

Street Address

Street Address Line 2

CityCounty

Postcode
Do you consider yourself to have a disability?

YesNo

Parent/Carer Details (2)
Name

PrefixFirst NameMiddle NameFamily Name
Email
example@example.com
Telephone

Area CodePhone Number
Is address same as child/young person's?

Yes
Address

Street Address

Street Address Line 2

CityCounty

Postcode
Do you consider yourself to have a disability?

YesNo

Child's Disability (please tick all that apply)

Level of Support Needs

	None	Unspecified	Low	Medium	High
Learning Disability
Physical Impairment
Hearing Impairment
Visual Impairment
Autistic Spectrum
ADHD
Long Term Health Condition
Challenging Behavious

Person Completing this Form
Name

PrefixFirst NameLast Name
The specific information provided by you on this registration form will only be shared with the Local Authority.

Support and Services currently being received or needed
Please indicate if you currently receive any of the following services by ticking the box labelled “currently received”. If you require a service but do not currently receive it then please tick the “needed” box. This information will assist councils to better plan services across Nottinghamshire – this form is not a means of requesting these services.

Education

	Currently Received	Needed
Special School (Day)
Special School (Residential)
Special educational equipment at school/college
Special Education Needs Team (City)
School and Families Specialist Services (County)
Autism Team (City)
Mainstream School
Portage
Parent Partnership Service
Transport to or from school/college
Sensory and Physical Team (City)
Learning and Support Team (City)
Further Education

Social Care

	Currently Received	Needed
Family Support Worker
Social Worker
Short Break (residential respite care)
Short Break (foster care)
Short break (other)
Welfare Rights Officer/Financial Advice
Childcare (for parents working/returning to work)
Direct Payments
Special equipment/adaptations
Transport (not to or from school)
Children's Centre
Play Group/Nursery
Childminding
Information Services

Health

	Currently Received	Needed
Health Visitor
Community Paediatric Nurse
Child and Adolescent Mental Health Services
Paediatrician
Occupational Therapy
Physiotherapy
Speech and Language Therapy
Dietician

Social and Leisure

	Currently Received	Needed
Sports Club
Theatre/Drama Group
Youth Services
Parks and Green Spaces
Cubs/Brownies/Scouts/Guides
Social Club
Faith Group
Leisure Centre

Other (please comment)
Date form submitted
Additional notes
Should be Empty: